Proper and adequate medical documentation is essential for quality of medical care and health care services throughout the industry, from receiving proper and correct treatment to receiving payment benefits from your health insurance provider.

Function of Medical Documentation

Why is important medical documentation vital? Without it, your health care would be compromised. One doctor wouldn't know what another doctor was doing. Without adequate documentation of visits, lab tests, treatments or surgeries, quality of care would certainly be erratic and potentially deadly. Medical documentation generally provides all the information about a specific patient that any doctor looking at a medical record would need to know to treat that patient. The patient's history is a vital piece of information that enables physicians to determine the best diagnosis and treatment plan for that individual, based on information found in the medical record.

Significance of Medical Documentation

Medical documentation is essential for standards of care to be met. In many scenarios, like those in acute care hospitals, many different health professionals may see the same patient, but not necessarily together. Your nurse, doctor, lab personnel and other specialists are all involved in your care, and everyone needs to be kept up to date with what everyone else is doing. Without such coordination, your medical care would suffer.

Medical Billing and Coding

Without adequate medical documentation, your health care providers might not be reimbursed for providing you with care, leaving you stuck with the bill. There's an old saying in the health care industry: "If it's not documented, it didn't happen." That means that if one of your health care providers forgets to write something in your medical record regarding a treatment, surgery or procedure that you received, the facility will not be paid for it--and you'll most likely be sent the bill. Without adequate documentation that you received such services, how can you prove it happened? In addition, such errors also compromise patient safety and quality of service.

Standards of Care

Neglecting to document important details of a patient's visit to a doctor's office may have huge ramifications for physicians at a later date. For example, if a doctor or nurse fails to note that a patient is allergic to penicillin, and the health care provider later injects the patient with penicillin, causing a severe allergic reaction, the doctor may be charged with negligence. Other scenarios where physicians fail to carefully and correctly document medical data can result in medical malpractice suits. Standards of care require all health care personnel to follow guidelines that ensure best judgment for proposed treatments. Documentation is also a legal protection for both patient and physician or other health care provider that protect both parties in the event of a disagreement over care.

Ethics

Adequate medical documentation assures patient confidentiality and ensures that standards of care are being met. Doctors and other medical personnel have an obligation to treat illnesses to the best of their ability in regard to information documented in a patient's medical record. Failure to do so compromises medical ethics and professional conduct.

References

About the Author

Denise Stern is an experienced freelance writer and editor. She has written professionally for more than seven years. Stern regularly provides content for health-related and elder-care websites and has an associate and specialized business degree in health information management and technology.